Sean Smith, MD

The rehabilitation of this patient population can be challenging due to complex medical histories and functional impairments. While many patients with advanced disease can safely undergo outpatient rehabilitation, others may need inpatient rehabilitation care. 

Rehabilitation in the Acute Care Setting

Inpatient rehabilitation is administered to patients primarily in three settings: acute care facilities, skilled nursing facilities, and long-term acute care facilities. In the acute care setting, patients are typically seen by both physical and occupational therapists. Patients’ tolerance for physical and occupational therapy can vary and is determined by their medical situation. 

Rehabilitation in this setting can be most useful for patients with medically complex issues, such as neutropenia or severe thrombocytopenia, and for those who need treatments requiring acute care hospitalization. One advantage is that the patient can receive rehabilitation while the acute care oncology service is managing medical complications. 

Jack B. Fu, MD

The cancer adaptation team is a model of rehabilitation care that has been used for decades at the Mayo Clinic to assist in discharge planning by performing a functional assessment of a patient, making recommendations for adaptive equipment and home modifications, and identifying community resources.¹ The core members of the cancer adaptation team include a physiatrist, nurse coordinator, occupational therapist, physical therapist, social worker, case manager, psychologist, and chaplain, to provide a more specialized rehabilitative program to inpatients while on the acute care service. A similar concept was implemented at The University of Texas MD Anderson Cancer Center to provide more intensive rehabilitation of up to 1 hour of physical therapy and 1 hour of occupational therapy daily on the acute care service with physiatry supervision. 

There are no regulations regarding the amount of therapy that can be provided on the acute care service. These specialized consultation-based programs provide rehabilitation services that are typically more comprehensive than what is normally provided on an acute care service. Staff availability, patient availability, and patient tolerance are obstacles to this type of comprehensive care. 

Also, the prospective payment system may create a financial disincentive for hospitals to provide more intensive rehabilitation while patients are receiving acute care. Eventually, patients will no longer meet acute care criteria, and an alternative inpatient rehabilitation setting must be pursued. Research has shown that performance status and patient satisfaction were improved in patients managed with this type of multidisciplinary care.¹

Acute Inpatient Rehabilitation

If a patient is able to tolerate at least 3 hours of therapy daily, acute inpatient rehabilitation, also referred to as inpatient rehabilitation facility, could be considered. For most payers, the ability to tolerate the intense 3-hour program is mandatory for admission to an inpatient rehabilitation facility. 

Acute inpatient rehabilitation can occur within an acute care hospital (usually on an inpatient rehabilitation floor) or in a freestanding rehabilitation hospital. While there are no formal rules regarding physician visits in an acute inpatient rehabilitation service, patients are typically seen every day or on weekdays only. Acute inpatient rehabilitation has been shown to improve physical function and restore independence in patients, regardless of the presence of metastases or whether tumors are solid or hematologic.^2,3

Many patients do not meet acute care criteria, are unable to tolerate 3 hours per day of therapy, and are not able to be safely discharged home. In these situations, patients can be cared for in skilled nursing facilities and in long-term acute care facilities. These facilities may be located within or next to an acute care hospital or as a freestanding building many miles away. Consideration of a patient’s medical complexity helps determine placement in these facilities. For example, skilled nursing facilities typically provide less frequent and less intense medical care than other inpatient rehabilitation settings. 

Although patients can be examined daily if necessary, they are typically examined only once or twice a week. More complicated medical treatments such as blood transfusions are not available at skilled nursing facilities. Long-term acute facilities provide more comprehensive medical care than skilled nursing facilities, and physician visits are typically more ­frequent.

Determining the Best Course of Care

Many physiatrists are uncomfortable caring for patients with advanced cancer and are reluctant to accept them for care. These patients typically have a higher rate of medical complications and more frequent transfers back to the primary acute care service than patients with earlier-stage disease.² Research efforts have been made to find predictors for which patients are at greatest risk for transfers back to the primary service.^4-9 

Predictors found in several studies include elevated creatinine levels, thrombocytopenia, and the presence of antimicrobial agents at the time of inpatient rehabilitation transfer. Consideration of such predictors would be useful to a consulting physiatrist or treating oncologist in determining the best course of care for patients. 

Patients with a higher likelihood of return to the primary acute care service may be better served by receiving rehabilitation within the acute care hospital setting. Their close proximity to oncologists and the intensive care unit may be useful if a serious medical complication occurs. Patients with lower probabilities for medical complications could receive inpatient rehabilitation at a freestanding rehabilitation hospital. When evaluating rehabilitation for these patients, physicians must also consider patients’ therapy tolerance and acute care criteria. ■

Disclosure: Dr. Fu reported no potential conflicts of interest. 

Dr. Fu is Associate Professor in the Department of Palliative, Rehabilitation & Integrative Medicine at The University of Texas MD Anderson Cancer Center, Houston.

References

1. Sabers SR, Kokal JE, Girardi JC, et al: Evaluation of consultation-based rehabilitation for hospitalized cancer patients with functional impairment. Mayo Clin Proc 74:855-861, 1999.

2. Sliwa JA, Shahpar S, Huang ME, et al: Cancer rehabilitation: Do functional gains relate to 60 percent rule classification or to the presence of metastasis? PM R 8:131-137, 2016.

3. Huang ME, Sliwa JA: Inpatient rehabilitation of patients with cancer: Efficacy and treatment considerations. PM R 3:746-757, 2011.

4. Alam E, Wilson RD, Vargo MM: Inpatient cancer rehabilitation: A retrospective comparison of transfer back to acute care between patients with neoplasm and other rehabilitation patients. Arch Phys Med Rehabil 89:1284-1289, 2008. 

5. Guo Y, Persyn L, Palmer JL, et al: Incidence of and risk factors for transferring cancer patients from rehabilitation to acute care units. Am J Phys Med Rehabil 87:647-653, 2008.

6. Asher A, Roberts PS, Bresee C, et al: Transferring inpatient rehabilitation facility cancer patients back to acute care (TRIPBAC). PM R 6:808-813, 2014.

7. Fu JB, Lee J, Smith DW, et al: Return to primary service among bone marrow transplant rehabilitation inpatients: An index for predicting outcomes. Arch Phys Med Rehabil 94:356-361, 2013.

8. Fu JB, Lee J, Smith DW, et al: Frequency and reasons for return to acute care in patients with leukemia undergoing inpatient rehabilitation: A preliminary report. Am J Phys Med Rehabil 92:215-222, 2013.

9. Fu JB, Lee J, Smith DW, et al: Frequency and reasons for return to the primary acute care service among patients with lymphoma undergoing inpatient rehabilitation. PM R 6:629-634, 2014.